 modernising other salaried dental
services so that they can make the maximum contribution to the
provision of dental treatment;

 the enhanced role of health authorities
and their new partnerships with providers of dental care, so that
anyone who calls NHS Direct looking for a dentist can be referred
to one;

 maximising the contribution of the
whole dental team, including professions complementary to dentistry
and women dentists who have encountered obstacles in their career
paths; and

 the potential of long term improvements
to working patternsfor example, more flexible intervals
between routine dental examinations.

2. The memorandum concludes by looking at
some relevant issues around the funding of NHS dentistry.

3. While a number of the measures in the
strategy are targeted clearly on delivering immediate improvements
to access, the strategy is designed just as much to raise the
overall quality of NHS dental care and to provide a firm foundation
for the future of NHS dentistry for decades to come.

4. The strategy signals the Government's
willingness to work with the profession and find long term improvements
to the working pattern of dentists. It also provides the basis
of a new, much stronger partnership between the NHS and dentists
at local level which will be crucial in ensuring a more effective
and integrated NHS dental service for patients.

INTRODUCTION

5. In July 2000 the Government published
the NHS Plan, which reaffirmed its commitment to improving access
to NHS dentistry (paragraph 12.8) and put dentistry firmly on
the NHS's future agenda. This was followed in September by a detailed
strategyModern NHS DentistryImplementing the
NHS Plan. This strategy expanded on the commitment and described
how it could be achieved, as well as describing plans for improving
the quality of NHS dentistry and of the nation's oral health.

6. The strategy acknowledges the nature
and origins of the access problem and is realistic about its scale.
It describes the measures and resources being devoted to improving
access to NHS dentistry by September 2001 and to sustaining that
improvement.

7. This memorandum avoids simply duplicating
the content of the strategy (although some repetition is inevitable).
It updates the strategy and describes the measures in more detail
and in the context of the Committee's terms of reference:

"To examine whether the Government's strategy,
Modernising NHS Dentistry, will improve access to NHS dentistry
in the long term."

BACKGROUND

8. The current statutory structure for dentistry
within the NHS has its roots in section 35 of the NHS Act 1977,
which begins:

"It is every Health Authority's duty, in
accordance with regulations, to make as respects their area arrangements
with dental practitioners under which any person in the area for
whom a dental practitioner undertakes in accordance with the arrangements
to provide dental treatment and appliances shall receive such
treatment and appliances."

9. The number of dentists working at least
partly in the General Dental Service (GDS) in England continues
to rise significantly year on year. At the last count there were
18,040, which is about 2,500 more than in 1992 when there was
no perceived access problem.

10. Nevertheless, during the 1990s many
more people began to have difficulty finding NHS dental treatment.
The reasons for that are described in the strategy, but can be
summarised as an ageing workforce, the increasing number of dentists
working part-time andmost significantlythe increasing
amount of time that GDS dentists devote to private practice.

11. The Government did not wait to publish
its strategy before tackling problems of access to NHS dentistry.
The measures described in Modernising NHS DentistryImplementing
the NHS Plan to build on the important action already taken.
The Investing in Dentistry scheme ran from 1997 to 1999. It is
still bearing fruit and has the potential to deliver access to
about two thirds of a million patients. In 1998 the Government
introduced the Personal Dental Services, including the first two
dental access centres.

12. While it will never be complacent about
the access problem, the Government believes the scale of the problem
needs to be kept in perspective. The most recent Office of Manpower
Economics survey (based on hours worked) shows that two thirds
of General Dental Practitioners (GDPs) do at least 80 per cent
of their work in the GDS and nearly 60 per cent of them do 90
per cent or more. The recent Adult Dental Health Survey, quoted
in the strategy, reported that nearly four out of five adults
said that they had their latest course of dental treatment under
the NHS.

13. In other words most dentists still spend
most or all of their time on NHS work and most people who want
it still get NHS dental treatment. This is despite the fact that
currently fewer than half the population are registered with a
GDS dentist (and even at the 1993 peak only a little more than
half were registered).

14. GDS dentists are independent contractors,
free to choose how to divide their time between the NHS and private
work. The strategy does nothing to encroach on that freedom. It
does, however, clearly demonstrate the Government's determination
to make NHS dentistry available to anyone who wants it.

15. The measures in the dental strategy
for improving access can be categorised under four broad headings:

 helping and ecncouraging GDS dentists
to do more NHS work;

 providing NHS alternatives to the
GDS where necessary, with an enhanced role for health authorities;

 making sure the entire dental workforce
(not just dentists themselves) is operating at optimum strength
and efficiency; and

 improving oral health and tackling
inequalities.

16. The rest of this memorandum describes
in more detail these measures and their effects on the availability
of NHS dentistry, cross-referenced to the relevant paragraphs
of the strategy document, and briefly considers some relevant
issues around the funding of NHS dentistry more generally.

DEVELOPINGTHE
GDS

NHS Direct (3.7-3.10)

17. A better exchange of information about
what dental services are available and where is a prerequisite
of improved access. It will benefit dentists and patients alike,
helping to make maximum use of the capacity available and to eliminate
any slack in the system.

18. NHS Direct is ideally placed to take
on and develop health authorities' existing role of advising those
seeking NHS dentistry. Currently two pilot projectsone
in the south west, the other in the north eastare testing
NHS Direct's ability to direct local callers to dental treatment.
The Government expects to extend this nationally by the summer.

Dental Care Development Fund (3.11-3.12)

19. The £4 million DCDF has been allocated
to health authorities. All HAs with any recognisable access problem72
out of 99received a share, weighted for the size of the
authority and the severity of their problem. The allocations ranged
from £15,000 to £125,000. The DCDF reflects the outcome
of consultation with the British Dental Association, which has
welcomed the Fund as an important initiative for NHS patients
and welcomed HAs' role in making it work.

20. HAs are using the money to reimburse
dental practices which expand and treat more NHS patients. The
average level of return required is 100 extra patients treated
per £1,250 of grant. HAs have considerable flexibility in
deciding how to use their resources and many supplement the central
allocation from their own funds. Nationally the Government expects
this year's DCDF to make NHS dental treatment available to up
to 250,000 more people by August this year.

21. Although the DCDF is designed to deliver
quick results, it is more than a short term measure. Dentists
who benefit from the Fund this year will have to maintain the
agreed level of extra NHS capacity for at least three years. The
Government is committed to extending the DCDF into 2001-02 if
that is necessary, and will allocate up to £6 million more
for that purpose. It will keep under review the need for similar
funding in future years.

Rewarding commitment to the NHS (3.13-3.14)

22. The strategy announced the detail of
a scheme rewarding the level of GDS dentists' commitment to NHS
work at a cost of about £20 million for 2000-01 in England.
This is a long-term commitment, and the Government has accepted
the recommendation of this year's report from the Review Body
on Doctors' and Dentists' Remuneration for increased rates of
payment in 2001-02.

23. The total level of the scheme was originally
recommended by the Review Body in its 2000 report and the Government
agreed the scheme's current structure with the BDA. Its aim is
to encourage more dentists to stay within the NHS and, where possible,
to increase their present level of commitment to the NHS. The
Government believes that these resources, together with the other
significant new resources which the strategy offers to committed
GDS dentists, can have a real and beneficial effect on the numbers
of GDS dentists offering NHS treatment.

24. The Government is working with the BDA
on a review of the structure of the commitment scheme to make
sure that it remains consistent with the objectives in the strategy
of rewarding loyalty to the NHS and helping up to a third of a
million more people get and keep access to NHS dentistry. That
review should be complete by April.

Modernisation Fund (3.15-3.16)

25. The Government is currently considering
the distribution of £35 million from the Treasury Capital
Modernisation Fund for the modernisation of committed NHS dental
practices, and the conditions to be attached to it. It is doing
so in conjunction with the BDA and will bear in mind the prevailing
access situation at the end of this financial year before deciding
what, if any, conditions relating to continuing or increased commitment
to NHS treatment should be attached to the payments. The benefits
for patients and dentists from modernised premises and equipment
will last for some years.

Modernised working patterns (4.37-4.39)

26. The strategy indicates how it may be
possible for the GDS to provide more, and more appropriate, treatment
through improved working patterns. It quotes the example of the
interval between routine dental examinationsmany patients
believe they should see a dentist every six months, many dentists
now feel that most people need only attend every year at most.
The potential for freeing up dentists' time is considerable, and
the Government will work with the profession to explore that potential
in full.

ALTERNATIVESTOTHE GDS

Dental Access Centres (3.17-3.22)

27. Last November the Government announced
the locations of the next wave of DACs. It expects DACs to be
operating from about 60 principal sites across the country by
April, able to treat about half a million patients a year. The
Government is currently considering the need for further DACs
to be established during 2001-02, taking into account the effects
of its whole programme of action and any gaps which might arise.

28. DACs are by their nature long-term arrangements
requiring a significant investment of resources in premises, staff
and equipment. As Personal Dental Service pilot projects individual
DACs will be formally evaluated after three years, but the early
evidence indicates that they are an invaluable tool for making
NHS dentistry available where GDS provision is inadequate.

29. DACs have been criticised for being
unable to deliver access to everyone who needs it. The strategy
is clear that most patients will continue to be treated within
the GDS, which is why most of the new resources are being directed
at the GDS. Access Centres will play a crucial part in providing
access to NHS care in the parts of the country where they are
needed most, but the Government's plans recognise that DACs alone
cannot solve the whole problem.

30. Neither are DACs in competition with
the GDS, either for patients or resources. DACs are established
where the GDS is not meeting local demand for NHS care. They are
not intended to treat patients registered with GDPs and will encourage
patients to register wherever possible.

Other Personal Dental Services (3.26-3.28)

31. The Government has written to health
authorities inviting expressions of interest for a fourth wave
of Personal Dental Services pilot projects. These projects will
also focus on access, supplementing the direct improvements offered
by DACs. This might be through:

 GDS projects addressing access in
areas of dental need, including through the skill mix of the dental
team; or

 service reconfiguration and modernisation
of existing Trust-led salaried services.

32. Fourth wave projects are expected to
be up and running from summer 2001 onwards. Like DACs, all PDS
projects will be evaluated formally after three years butagain
like DACsthe Government expects them to make a significant
contribution to improved access both in the short term and for
years to come.

Modernising other salaried dental services (3.32-3.34)

33. There is already a significant investment
in the Community Dental Service in many places, over and above
that in any local Dental Access Centres. The Government believes
that the way HAs have commissioned CDS can be improved and so
fulfil the potential of the service for addressing local dental
needs.

34. HAs have been asked to appraise the
scope for enhancing existing CDS services through additional investment
of capital or revenue. This could mean better use of existing
clinical facilities, increasing staff numbers, better support
for management and investment in improved premises and equipment.

35. None of this should affect adversely
the services and functions which are already being provided by
the CDS. The aim is for a permanent enhancement of the whole performance
of CDS, not a shift of resources which reduces the ability of
the CDS to fulfil its existing functions.

New partnerships and HAs' role (3.23-3.25)

36. The Government believes that its centrally-funded
initiatives will have a major impact on access problems. Working
in parallel, health authorities must also monitor the local situation
and be ready to intervene in new ways, making sure that NHS dental
care is available to everyone who needs it.

37. The dental strategy describes the sort
of new partnerships with providers of dentistry that the Government
expects HAs to enter into if they are required. HAs are benefiting
from the largest sustained increase in funding in the history
of the NHS, and the Government is making it clear that this provides
an opportunity to move dentistry up the local NHS agenda permanently.

38. The NHS Executive's performance management
arrangements now reflect that. For example, every regional office
of the Executive has nominated a lead director to take responsibility
for implementing the dental strategy and health authorities have
been asked to do the same. Any authority experiencing problems
will be identified and offered advice and assistance.

39. The Government is currently preparing
detailed guidance for HAs on how the new partnerships should work.
It envisages Personal Dental Service contracts between HAs and
providers, creating reliable and stable mechanisms for offering
NHS dental treatment to anyone referred by NHS Direct even where
no local GDS dentist is accepting new registrations and there
is no convenient Dental Access Centre.

WORKFORCE ISSUES

40. The last review of the requirement for
dentists was completed in 1987 when a quota of 805 undergraduate
admissions to dental schools per annum was set. In fact, due to
the popularity of dentistry as a career and the high calibre of
applicants for places in dental schools, this quota has regularly
been exceeded in recent years. In the 1999-2000 session 877 students
entered UK dental schools. There were 4,185 students in training
in January 2000, of whom some 95 per cent were from the UK. This
figure is similar to the 4,193 students in training in January
1999.

41. The Dental Advisory Sub-Group of the
Medical Education, Training and Staffing Committee (DAGMETs) initiated
a new review in 1998. At the time of the 1987 review the number
of dentists on the Dental Register was projected to grow by 14
per cent, from 24,500 in 1985 to 28,000 by 1995. The actual increase
was very close to this. There has been a marked change in the
proportion of male to female dentists and, with the more flexible
working patterns adopted by some women dentists, it has been estimated
the whole-time equivalent of the Dentist Register in 1995 was
about 19,000. By January 2000 the number on the Register had increased
to 31,000, equivalent to about 21,000 whole-time dentists.

42. On the demand site, population growth
has exceeded the 1987 estimate. In 1987 the population of the
UK was expected to reach a total of 58.1 million by 1996, but
it had already reached 58.8 million by 1996 and further divergence
from 1987 projections is expected.

43. The fall in the percentage of adults
without natural teeth was underestimated. In 1987 a UK rate of
16.8 per cent was predicted by 1995 (compared to a rate of 23.2
per cent in 1985) but the actual 1995 level was 15 per cent. There
also seems to have been a change in attitudes to dental care.
People have become more health-aware, and also more aware of what
dentists can do for them cosmetically. The proportion of adults
with natural teeth claiming to see a dentist for a regular check-up
has increased by some 6 per cent since 1987.

44. Future plans to extend duties of dental
therapists and dental hygienists and introduce new classes of
professionals complementary to dentistry such as clinical dental
technicians and orthodontic therapists will expand and enrich
the skills mix of the whole dental team. The potential of the
extended role of professionals complementary to dentistry needs
to be considered before final conclusions on workforce requirements
are drawn (paragraphs 4.41-4.46 of the dental strategy).

45. In April 2000 the Department of Health
published a consultation document A Health Service of all the
talents: developing the NHS workforce which proposed a more
integrated approach to work force planning and the creation of
a new National Workforce Development Board to oversee the new
arrangements. A sub-group of the Board will take forward the DAGMETS
review by addressing the planning of the dental workforce, including
dentists and professionals complementary to dentistry, to meet
the future staffing implications of the dental strategy.

46. Also, to achieve a better understanding
of the career aspirations and working patterns of women in NHS
dentistry the Chief Dental Officer, Dame Margaret Seward, is carrying
out a study of barriers to women making the fullest contribution
to dentistry, with a view to improving employment opportunities
for women dentists. Dame Margaret expects to complete her report
by 31 March.

47. In summary, the Government feels there
are three major issues to be addressed before reaching firm conclusions
about whether the overall dental workforce is of an appropriate
size to meet the population's dental care needs:

 the development of team working in
which the skills of all dental professionals are used to full
effect;

 the potential of better rewarding
commitment to the NHS to increase the proportion of time dentists
work in the NHS; and

 a better appreciation of the career
ambitions of dentists, including any changes in terms and conditions
necessary for them to accommodate domestic responsibilities within
their chosen career pattern.

IMPROVING ORAL
HEALTH

48. Much of Chapter 3 of Modernising
NHS DentistryImplementing the NHS Plan 1 is about meeting
unmet demand for dentistry. Chapter 5 of the strategy addresses
the related, but not identical, issue of unmet need through measures
aimed at improving oral health and reducing inequalities.

49. Experience shows that relatively small
schemes can be effective in introducing large numbers of children
to good oral health practice (paragraphs 5.11-5.13 of the strategy).
In the current financial year the Government is making available
about £0.5 million to fund schemes where children's oral
health is poorest.

50. The oral health of black and minority
ethnic groups can be relatively poor, for a number of reasons
(2.8). The Government and the NHS will continue to address this
issue and work with the National Transcultural Oral Health Centre
(5.19-5.21).

51. Because there is no single cause of
oral health inequality the strategy describes how the problem
will be tackled on a number of new frontsfor example Health
Action Zones, Healthy Living Centres and the Sure Start initiative
(5.23-5.28). The strategy also announced the Government's intention
to set new targets for oral health, for both children and adults
(5.7).

Fluoridation

52. The York University review into the
effects on health of fluoridation clearly shows that fluoridating
water helps to reduce tooth decay. In areas where overall health
is lower than average, dental health is much higher if the water
is fluoridated. The report also identified the need for more good
quality research and we are asking the Medical Research Council
to suggest where it is possible to carry out further research
to strengthen the evidence currently available to us.

53. The Government will encourage health
authorities with particular dental health problems to consider
fluoridating their water as part of their overall oral health
strategy. We will be having further discussions about this with
the water companies and local authorities.

FUNDING ISSUES

54. It is sometimes alleged that access
problems are a result of under-funding of NHS dentistry and that
access cannot be improved as long as private practice is more
profitable than NHS work.

55. The NHS fee scale which comprises dentists'
income from NHS work falls within the remit of the independent
Review Body on Doctors' and Dentists' Remuneration, whose recent
reports have concluded that dentists' earnings were broadly reasonable
and in line with those of comparable professions.

56. Average annual earnings (after expenses
but before tax) of a full time dentist who does only NHS work
are now about £60,000. The Government believes that is fair.
Most dentists also do at least some private work which takes their
earnings higher. Earnings now include the scheme rewarding dentists'
commitment to the NHS, which has added up to £4,500 a year
to dentists' NHS income.

57. The Review Body also commissioned a
survey into dentists' hours of work and workload. According to
that, a full time, wholly committed GDS dentist works on average
42.3 hours a week and sees 139 patients while the average for
all dentists (including those who do private work) is 43 hours
and 122 patients. The Government's consideration of the dental
workforce, the Personal Dental Service pilot projects looking
at new ways of delivering dentistry and remunerating dentists,
and other possible changes to working patterns all indicate the
Government's willingness to keep workload issues under constant
review.

58. Most of the £100 million in the
strategy will be paid to GDS dentists to improve their working
environment and treat NHS patients. Expenditure on the GDS in
2000-01 is projected to reach a level 8 per cent higher in real
terms than in 1997. Meeting the Government's target of treating
another two million people will add about £80 million a year
to DGS spending. There are PDS projects testing alternative ways
of remunerating dentists (para 3.26 of the strategy) which will
be evaluated in due course.

CONCLUSION

59. The Government knows it has set an ambitious
target for access to NHS dentistry but is determined to meet it.
The commitment to developing NHS dentistry will not end there.
The Government will continue to work closely with the profession
and the NHS, who both have crucial roles in meeting the target
for improved access and sustaining the improvement for the future.
The new resources and mechanisms that the Government is making
available, and the drive for better working patterns it is setting
in motion, represent a golden opportunity to change the delivery
of NHS dentistry for better and for good.